Sunday, June 24, 2012

Trauma and Critical Care at Charlotte Maxeke Johannesburg Academic Hospital in Johannesburg, South Africa, Jayamaran

Sudha Jayaraman MD MSc
Fellow, Trauma Burns and Surgical Critical Care
Brigham and Women's Hospital

Pictures worth a 1000 words....

This is a CT scan of the chest of a young man with stab wound to the chest - he was hemodynamically stable on presentation but the location of the wound was concerning for cardiac injury and risk of tamponade. Because echocardiography is not readily available, a CT was performed and shows substernal air pockets just anterior the heart and aorta. While he may have been observed in the ICU and followed with serial echo exams in the American setting, lack of close monitoring capacity in the ICU, difficulties in mobilizing an operating room in case of sudden tamponade and lack of echo facilities meant that this patient needed an immediate pericardial window and if positive, a sternotomy to assess and possibly repair the likely injury to the heart.

Below- Intraoperative photograph showing open pericardium with a small (2mm) injury to the right heart. The injury had stopped bleeding and did not require further repair. This was a non-therapeutic sternotomy.

Trauma Resuscitation Bay in the Emergency ward at Baragwanath Hospital. Up to 16 patients can be managed and ventilated at one time. Considered the largest trauma center in the world.

Milpark Hospital, a private facility for insured patients, has a beautiful 30 bed Trauma ICU and a 10 bed Burn ICU, pictured below, with state of the art equipment and staff. The helipad is right in front of the entrance.

Trauma and Critical Care at Charlotte Maxeke Johannesburg Academic Hospital in Johannesburg, South Africa


Despite stark disparities and severe resource constraints, the people I worked with every day were an incredible source of inspiration. The faculty, trainees and students were an incredibly diverse group of people of every race, color and religion. They were collegial, thoughtful and compassionate to each other and to me.

In the picture below is Nadine (right), one of the graduating surgical residents at Wits. I spent quite a bit of time with her during my trip and found out that she is a truly remarkable woman. She was technically excellent in the operating room. She also blew the socks of a lot of the nursing staff when she switched between speaking with me in English, to talking to some of the staff in Afrikaans and the patients in Zulu. It also turns out she is a mother of two young children. It was quite endearing when she asked to come in late one morning so that she could sing “Happy Birthday” to her older child at the school party. I was even more impressed when her faculty supported her and allowed her to come in late!

Reuven, one of the faculty surgeons at Joberg Gen, is pictured below. I had the pleasure of working with him quite closely and he was absolutely amazing in the depth of his commitment and compassion to his patients. His passion and intensity were just extraordinary. Reuven’s main interest is in pediatric trauma and he is focused on improving the care that injured children receive in Joberg. He also directs one of the private ambulance companies in Joberg and supervises dozens of volunteer first-responders who provide on-scene care in the community. Joberg, a historic gold mining town, has hit gold in having Reuven to take care of its injured public. Hopefully, the push and pull of brain drain doesn’t taken him away from where he is needed most – at home in Joberg!

Many thanks to Nadine and Reuven as well as Profs. Goosen and Boffard, Ismael Cassimjee, Steve Moeng, Frank Plani, Denis Allard among the many other residents, medical officers, students and nurses who made my trip as successful as I had hoped for and then some!

Sudha Jayaraman MD MSc
Fellow, Trauma Burns and Surgical Critical Care
Brigham and Women's Hospital

Trauma and Critical Care at Charlotte Maxeke Johannesburg Academic Hospital in Johannesburg, South Africa

Disparities, conundrums and contradictions

The most striking aspect of my visit to Joberg was the recognition of disparities on many different levels. I didn’t realize that South Africa has among the highest Gini coefficients of all the countries around the world per the World Bank but I certainly noticed it very quickly during my trip. (The Gini coefficient is a measure of income inequality with high values indicating greater disparities in income distribution.)
Obviously there are disparities between the US and SA in the quality of healthcare which is largely related to disparities in health care funding between the two countries -18% of GDP in the US is spent on health care versus 9% is SA per the World Bank.

However, disparities in income and class were quite stark. There is a clear predominance of black South Africans in the public hospitals, for example, compared to the wealthier white and Indian population in the private facilities. This difference was noticeable in general society as well. Joberg is known for its fancy malls with all the most famous high-end European and American clothing and accessory shops. Visit one of them and disproportional distribution of black waitstaff and a largely white clientele is quite obvious. Capetown, which I visited for 2 days, had the same skew in the staff and clientele in the posh restaurants lining the coast.

There were also striking disparities in care between hospitals in Joberg. I was struck by the differences between the public and private hospitals in the city. While the same surgical faculty worked at both the public hospitals (Joberg Gen and Baragwanath Hospital) and the private hospitals (Milpark and Donald Gordon), I could not help but notice the differences in resources between these facilities. The 30 ICU beds at Milpark that are solely allocated to trauma patients compared to the 4 ICU beds at Bara which meant that a ventilated patient at Bara might end up on the general surgical ward along with 60+ other patients.

The disparate burden of trauma, especially on black versus white and Indian children, was painful for me to see, especially as a mother of an active three-year old. Every day I passed kids of all ages as I walked through two of the most elite private prep schools in the country on my way in to the hospital – St. John’s (boys) and Rodean (girls). The schools were largely filled with white and Indian children with a significant but small minority of black children. The casualty ward at Joberg Gen told the opposite story every night.

The first Friday and Saturday nights I spent on call I saw five young black South Africans die. They were between the ages of 15 and 30.

At Bara, on one of the few nights I visited, I saw four black children, from different families, present with large burns. They were all under the age of three.

It is winter in Joberg and the evenings/nights can get quite cold (30s Fahrenheit). Poorer families often use open air fires for warmth or for cooking and children can easily become casualties.

Ninety percent of deaths from injury happen in low and middle income countries while the majority of research and funding for trauma are focused in high income countries. My visit to Joberg Gen only made me more acutely aware of that disparity and made me more convinced that I should be part of efforts to change that inequality.

Sudha Jayaraman, MD MSc
Fellow, Trauma Burns and Surgical Critical Care
Brigham and Women's Hospital

Friday, June 15, 2012

Community Health Workers and expanding primary care in rural Uganda, Paul J. Krezanoski, MD

Another discovery on my recent trip to Uganda is the growing use of technology to augment the ability of lower skilled health workers to improve care delivery. The Healthy Child Uganda cell phone project, funded by an aid organization from Canada, is a perfect example.

They have piggy-backed a cell-phone based technology project onto a Uganda national government initiative to utilize communty based health workers. These health workers are designated by their communities as respected leaders at the village level. Depending on the size of the village, there is usually 1-3 CHWs identified. Their typical job is to help with training and mobilization for vaccine campaigns and other national priorities.

Healthy Child Uganda has rolled out a full scale point-of-care treatment program using cell phone technologies. They have programmed phones with interactive algorithms that CHWs use to treat the patients they see in the villages. Using the age of the child, the symptoms and a checklist of red flag symptoms, teh algorithm designates intital treatment options (amoxicillin for fast breathing (?pneumonia) or artersunate for fever (?malaria)). Then, based on the symptoms, the phone will recommend referral to a local clinic and automatically update that clinic of what to expect via a web application.

They are using this platform for stock delivery of medications at the CHW and clinic level and have a sophisticated web application which provides real-time data about what cases the CHWs are seeing in the field categorized by age, symptom and geographic location.

The hope is that these sorts of low-end technological solutions are gonig to allow the health systems in poor countries to overcome logistical challenges to provide higher quality primary care in remote locations. I thought this was a great example of that concept.

Wednesday, June 13, 2012

Trauma and Critical Care at Charlotte Maxeke Johannesburg Academic Hospital in Johannesburg, South Africa

I joined the Trauma Unit at the University of Witwatersrand Medical School, Charlotte Maxeke Johannesberg Academic Hospital at a volunteer faculty surgeon for a few weeks last month.  It was my first time in South Africa although I had worked and travelled in Uganda and Mozambique before. 

I chose to spend some time at this particular hospital for several reasons.  This hospital and it's sister facility (Baragwanath Hospital) are world renown as high volume trauma centers and have produced many international leaders in trauma care such as Dr. Demetriades (Chief of Trauma at LA County/USC Hospitals) and Dr. Velmahos (Chief of Trauma at MGH), among others.  As such, these two facilities draw visiting faculty, trainees and medical students from around the world.  As a Trauma and Acute Care Surgery Fellow at the Brigham, I was drawn to visit, observe and participate in these settings which trained some of the most remarkable surgeons in my field.

Furthermore, I am particularly interested in how systems of trauma and emergency services are developed, both locally in the United States and globally.  Through a collaboration between UCSF and Mulago Hospital in Kampala, Uganda, I was able to work on injury-related research during my residency and plan to continue work along those lines in Rwanda in the upcoming years through BWH/PIH.  Thus I have wanted to learn about how the South African health system is set up to address trauma and emergency services and determine what lessons I can gather for my upcoming work in Rwanda.

Here are a few photos from my first day at Joberg General.  It was a fantastic institution to visit and a great group of faculty and residents to work with during my three weeks there. 

More postings to come about the details of my time there....

Sudha Jayaraman MD MSc
Fellow, Trauma Burns and Surgical Critical Care
Brigham and Women's Hospital

Univ of Witwatersrand Medical School

Charlotte Maxeke Johannesberg Academic Hospital (Joberg General)

Trauma Resuscitation Bay

Bedside in the Trauma ICU

Monday, June 11, 2012

Use of bednets in rural Ugandan households, Paul J. Krezanoski, MD

My work in Uganda is related to understanding the determinants of the use of bednets. These insecticide-treated nets have the potential to dramatically improve the lives of pregnant women and their children. Mere ownership in a household has been correlated with a 20% decrease in mortality among children under 5 years of age.

Uganda and especially western Uganda, has a very high level of malaria. It is a significant burden on the health system and leads to lives lost and time away from work. Bednets are often too expensive for households and even when they own them, they don't always use them as they are meant to be used.

I spent multiple afternoons visiting households in rural villages trying to understand the barriers to bednet use. This usually involved trekking into the banana trees with a local health worker and showing up at households. The first thing they would always do is invite us in to their homes. No matter how poor, they always invited us in, asked us to sit and thanked us for coming.
In many of the households, the walls were made of crumbling mud caked onto wooden frames. The ground was packed dirt and there were only a few small (small) rooms. The bednets I saw typically took up the whole space of the bedroom. Challenges included keeping them clean, finding creative ways to mount them in such small spaces, and finding ways to put them up adequately over sleeping areas.

I spent a lot of time asking people about their perceptions of bednets and their understanding of why they are used. We also discussed local programs for bednet distribution and ways that the people thought these programs could be improved. Often I would talk with the village health worker after I'd left the houeshold to get the "real scoop" about that household's malaria behaviors. I heard about husbands who refuse to sleep under the nets for fear of reducing their sperm count. I heard about how nets make people too hot so they aren't used in the humid rainy season (the time they are most needed). I heard about bednets made into wedding veils for local celebrations.

There is much to learn about how this technology makes it way into the real lives of local people. And that is where I am focusing my work.

Paul J. Krezanoski, MD